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Delirium is a common, serious, underdiagnosed condition in medical and surgical inpatients with acute conditions. It is associated with increased risk of mortality and morbidity. Data of geriatric cohorts are largely limited to developed countries.To describe prevalence, risk factors and outcomes of delirium among general medical patients admitted to two hospitals in Cape Town, South Africa.This was a prospective cohort study of patients with acute conditions admitted to a general medical inpatient service in secondary- and tertiary-level public hospitals in the Metro West area of Cape Town. Patients ≥18 years of age were recruited daily from all acute medical admissions. Patients were excluded if they were aphasic or their Glasgow coma scale waslt;8/15. Delirium was diagnosed using the validated confusion assessment method (CAM) tool and performed by trained neuropsychologists. Demographic data were collected by a clinical team and short- and long-term mortality data were obtained using linkage analysis of hospitalised patients and routinely collected provincial death certification records.The median age of inpatients was 51 (interquartile range 36 - 65) years, 29% were HIV-infected and the overall prevalence of delirium was 12.3%. Multivariate predictors of delirium included the presence of an indwelling urinary catheter (odds ratio (OR) 4.47; confidence interval (CI) 2.43 - 8.23), admission with a central nervous system disease (OR 4.34; CI 2.79 - 7.90), pre-existing cognitive impairment (OR 3.02; CI 1.22 - 7.43) and immobility (OR 1.88; CI 1.01 - 3.51). HIV infection was not associated with increased risk of delirium. Delirium was associated with an increased risk of inhospital (delirium v. no delirium: 29% v. 12%; plt;0.01) and 12-month (30% v. 20%; plt;0.01) mortality, as well as increased length of hospital stay (7 days v. 5 days; plt;0.01).In this cohort of medical inpatients (relatively young and with a high HIV prevalence) 1 of 8 (12.3%) patients was delirious. Delirium was associated with adverse outcomes. Delirium risk factors in this young cohort were similar to those in geriatric cohorts in developed countries, and neither HIV nor opportunistic infections increased risk.

Background. Delirium is associated with increased mortality and length of hospital stay. Limited data are available from HIV-infected acute hospital admissions in developing countries. We conducted a prospective study of delirium among acute medical admissions in South Africa (SA), a developing country with universal antiretroviral therapy (ART) access and high burdens of tuberculosis (TB) and non-communicable disease. Objectives. To identify the prevalence of, risk factors for and outcomes of delirium in HIV-infected individuals in acute general medical admissions. Methods. Three cohorts of adult acute medical admissions to Groote Schuur and Victoria Wynberg hospitals, Cape Town, SA, were evaluated for prevalent delirium within 24 hours of admission. Reference delirium testing was performed by either consultant physicians or neuropsychologists, using the Confusion Assessment Method. Results. The study included 1 182 acute medical admissions, with 318 (26.9%) HIV-infected. The median (interquartile range) age and CD4 count were 35 (30 - 43) years and 132 (61 - 256) cells/µL, respectively, with 140/318 (44.0%) using ART on admission. The prevalence of delirium was 17.6% (95% confidence interval (CI) 13.7 - 22.1) among HIV-infected patients, and delirium was associated with increased inpatient mortality. In multivariable logistic regression analysis, factors associated with delirium were age ≥55 years (adjusted odds ratio (aOR) 6.95 (95% CI 2.03 - 23.67); p =0.002), and urea ≥15 mmol/L (aOR 4.83 (95% CI 1.7 - 13.44); p =0.003), while ART use reduced risk ( p =0.014). A low CD4 count, an unsuppressed viral load and active TB were not predictors of delirium; nor were other previously reported risk factors such as non-opportunistic acute infections or polypharmacy. Conclusions. Delirium is common and is associated with increased mortality in HIV-infected acute medical admissions in endemic settings, despite increased ART use. Older HIV-infected patients with renal dysfunction are at increased risk for inpatient delirium, while those using ART on admission have a reduced risk.

Background Clinical remission is widely accepted as the primary target outcome for juvenile idiopathic arthritis (JIA). PR-COIN is a quality improvement collaborative that serves as a sample of pediatric rheumatology centers in North America. By measuring disease activity in practice using the ACR provisional criteria for Clinical Inactive Disease (CID), variation in patient outcomes has been previously observed between centers. Objectives The objective of this study was to evaluate differences in patient-level factors that may be driving center-level variation in JIA outcomes. Methods This study used cross-sectional data provided by PR-COIN that was collected by PR-COIN centers from March 2015 to May 2016. For each patient, sociodemographic, clinical, patient-reported, disease activity, and medication variables were extracted from the most recent encounter. Patients with disease duration less than 9 months were excluded. Patients were grouped by CID status (inactive vs active disease) and then compared using descriptive statistics, chi-square for categorical variables, and independent t-tests for continuous variables. Missing data were excluded with each analysis. Analyses were performed using R software. Results There were 2751 patients eligible for analysis from 14 centers, with 33 to 394 patients per center. We identified 1249 patients with inactive disease (47%) and 1428 patients with active disease (53%). Patients with inactive disease were younger (12 vs 13 years), more likely to have persistent oligoarticular subtype (33% vs 23%), and less likely to have enthesitis related arthritis (9% vs 14%). Patients with active disease had higher patient-reported measures of global assessment of disease activity, pain, and functional disability, as well as disease activity measures per definition. More medication usage was observed in patients with active disease compared to inactive disease across multiple categories, including both non-biologic DMARDs (45% vs. 32%) and biologic DMARDs (48% vs 35%). Conclusion This study demonstrates differences in sociodemographic, clinical, and medication factors between patients with inactive and active JIA. Further analysis is needed to adjust center-level measures of JIA disease activity using the observed differences in patient case-mix. By using population data to identify predictors of inactive disease in JIA, there is potential to develop and implement targeted clinical interventions to directly impact care and improve outcomes. Disclosure of Interests: Emily A. Smitherman: None declared, Bin Huang: None declared, Ronald Laxer Consultant for: Eli Lilly Canada, Alexion, Sanofi, C. April Bingham: None declared, Cagri Yildirim-Toruner: None declared, Beth Gottlieb: None declared, Jennifer E. Weiss: None declared, Tzielan Lee: None declared, Sheetal Vora: None declared, Jon (Sandy) Burnham: None declared, Julia G. Harris: None declared, Judyann C. Olson: None declared, Mileka Gilbert: None declared, Michelle Batthish Speakers bureau: Novartis, Abbvie, Michael Shishov: None declared, Dustin Fleck: None declared, Esi Morgan: None declared

Autoimmune polyendocrinopathy with candidiasis and ectodermal dystrophy (APECED) is a rare disorder of immune dysregulation caused by mutations in the autoimmune regulator (AIRE) gene. Individuals affected with APECED develop a clinical syndrome characterized by ectodermal abnormalities, autoantibody production, and organ-specific autoimmune manifestations. Inflammatory arthritis is usually not described as a part of the syndrome, and only sporadic cases are reported. We describe the case of a preschool-age girl who presented with hypoparathyroidism, hepatitis, interstitial pneumonitis, and chronic polyarthritis at 4 years of age and was found to have two compound heterozygous disease-associated mutations in the AIRE gene. We also conducted a literature review of the main characteristics of inflammatory arthritis in APECED patients. Our case and review demonstrate that (1) inflammatory arthritis, although rare, can be an early manifestation of APECED; (2) the diagnosis of APECED should be considered if mucocutaneous candidiasis, multiple organ-specific autoimmune manifestations, polyendocrinopathy, especially hypoparathyroidism or adrenal failure, or ectodermal dystrophy accompany joint symptoms; and (3) genotyping interpretation should take into account that mutations are found in the 14 exons of the gene, compound heterozygosity is common, and in some cases, only one or no mutated alleles are found.

Autoimmune polyendocrinopathy with candidiasis and ectodermal dystrophy (APECED) is a rare disorder of immune dysregulation caused by mutations in the autoimmune regulator (AIRE) gene. Individuals affected with APECED develop a clinical syndrome characterized by ectodermal abnormalities, autoantibody production, and organ-specific autoimmune manifestations. Inflammatory arthritis is usually not described as a part of the syndrome, and only sporadic cases are reported. We describe the case of a preschool-age girl who presented with hypoparathyroidism, hepatitis, interstitial pneumonitis, and chronic polyarthritis at 4 years of age and was found to have two compound heterozygous disease-associated mutations in the AIRE gene. We also conducted a literature review of the main characteristics of inflammatory arthritis in APECED patients. Our case and review demonstrate that (1) inflammatory arthritis, although rare, can be an early manifestation of APECED; (2) the diagnosis of APECED should be considered if mucocutaneous candidiasis, multiple organ-specific autoimmune manifestations, polyendocrinopathy, especially hypoparathyroidism or adrenal failure, or ectodermal dystrophy accompany joint symptoms; and (3) genotyping interpretation should take into account that mutations are found in the 14 exons of the gene, compound heterozygosity is common, and in some cases, only one or no mutated alleles are found.

Objective To describe the course of patients with juvenile dermatomyositis (JDM) treated effectively without systemic corticosteroids. Study design A retrospective study of 38 patients with JDM treated at a tertiary care children's hospital identified 8 patients who had never received corticosteroids. Disease presentation and course, pharmacologic, and ancillary treatments were recorded. Results Patients in the no corticosteroid group were followed for a median of 2.8 years (range, 2.1 to 9.5 years). Treatment was primarily with intravenous immunoglobulin (IVIG) (75%) and methotrexate (50%), with favorable response in all. No serious treatment complications were observed; headaches were reported by 3 patients receiving IVIG. Two patients had a myositis flare after discontinuing all medications for more than 1 year; complete resolution of symptoms was observed after either 1 or 2 further doses of IVIG. Two patients had calcinosis (at 1 and 9 years of disease); however, no patient had joint contractures, muscle atrophy, lipodystrophy, or functional limitations. Conclusions Systemic corticosteroids can be avoided in a select group of patients with JDM. Alternative agents such as methotrexate and IVIG may be prescribed to effectively treat JDM and prevent complications.

Aqueous biphasic systems (ABS) represent wholly aqueous systems that are safe, nontoxic, nonflammable, and relatively environmentally benign as extraction media. We have studied detailed phase diagrams and partitioning data currently used in wholly aqueous solvent extraction or reactive extraction processes that may be applicable to the delignification of cellulosic materials at elevated temperature. The study results indicate that increasing the concentration of salt improves the degree of phase divergence. The partitioning results of different lignin species in PEG/salt ABS show that lignin prefers the polymer-rich phase of ABS. Four complete time-at-temperature (130-160°C) batch-cooking experiments were made using a Kraft pulping solution with and without PEG. The results for wood chips composed of a mixture of southern hardwood indicate that the use of PEG results in a pulp with lower Kappa number, lower lignin content, higher residual pulp yield, and reduced alkali consumption.

Metal salts (MgSO4 and Li2SO4) that serve to catalyze wood delignification and also contribute to the formation of aqueous biphasic systems (ABSs) have been studied. The influence of treatment conditions on the pulp properties (measured as the kappa number, residual pulp yield) has been determined by means of a 24 factorial design. The effects of the variables (temperature, time, salt, and polymer concentration) have been determined. Wood and pulp samples and lignin resulting from this process have been characterized by scanning electron microscopy (SEM) and Fourier transform infrared (FTIR) spectroscopy.

The application of polymer-based aqueous biphasic systems (ABSs) to the alkaline paper pulping process is reported. ABSs composed of polymers and pulping solution (a mixture of NaOH, Na2S, and Na2C...

Conventional water treatment techniques typically suffer from severe limitations in selective removal and recovery of heavy metals from dilute solutions. For instance, treatment by pH control, chemical reduction, and chemical oxidation result in precipitation of heavy metaJs, which are subsequently landfilled. Ion exchange suffers from lack of selectivity in cation removal from multi-component mixtures, while electrochemical reduction has severe limitations in dilute solutions. In order to address the problem of selective heavy metal removal and recovery, development of the Membrane-Electrode (M-E) process was undertaken. The M-E process is a hybrid of electrochemical reduction and ion-exchange technologies and permits selective ion-exchange from dilute aqueous solutions. High cation selectivities in the M-E process is due to controlled rate of ion-exchange. It has been discovered that cation exchange rates can be controlled by application of an electrical potential difference (pd), and that an inverse re...

Selective cation recovery from dilute, aqueous, multi-cation waste streams addresses a solution method to a class of problems with worldwide implications. The absence of large scale systems to handle such waste streams and severe limitations of conventional technologies have been the motivating forces behind the development of the membrane–electrode (M–E) process. Thus far, the M–E process has been effectively demonstrated for selective recovery of Pb 2+ and Cu 2+ ions from dilute aqueous binary cation solutions [V. Gopal, G.C. April, V.N. Schrodt, Selective removal of copper from multi-cation dilute aqueous solutions using the membrane–electrode process, J. Sep. Sci. Technol. 33 (5) (1998) in press]. This paper extends coverage to Pb 2+ ion recovery from a mixture containing Pb 2+ ions and Fe 2+ ions. It is found that the applied cathodic potential is the parameter controlling the rate and selectivity of ion-exchange in the M–E process. An inverse relationship exists between the applied cathodic potential and rate of ion-exchange, while a direct relationship exists between the applied cathodic potential and Pb 2+ ion selectivity.

The presence of metallic contaminants (in the form of cations) in wastewater streams has long been a source of concern to process industries. Conventional methods of removal of metallic components from wastewater result in products which have little or no further use and are subsequently Iandfilled (6). This research involves developing a method, i.e., the membrane-electrode (M-E) process, to selectively re-cover heavy metals from dilute aqueous waste streams (cation concentrations less than 1000 ppm) in forms that can be recycled. Preliminary results for copper—nickel systems are presented to demonstrate the selectivity of this new treatment method.

Project ROSE is a non-profit energy conservation program funded by the Alabama Department of Economic and Community Affairs, Science, Technology and Energy Division and sponsored by the University of Alabama. Project ROSE's goal is conserving energy, preserving a valuable natural resource and protecting the environment. To accomplish its purpose, Project ROSE educates the public recycling used oil, helps establish used oil recycling programs, and offers used oil collection and recycling assistance. Project ROSE has served the people of Alabama and the nation since 1977.

Background/Purpose: The Pediatric Rheumatology Care and Outcomes Improvement Network (PR-COIN) is a multi-center, quality-improvement-focused learning network with a mission of improving outcomes for children and adolescents with juvenile idiopathic arthritis (JIA). PR-COIN has developed a population management tool which facilitates pro-active, coordinated health care communications and interventions that can be used in managing JIA patient populations. Methods: The population management tool was developed with information technology expertise to link seamlessly to the PR-COIN longitudinal registry. Within the population management tool, on demand reports can be generated using participating site or aggregate, network level data according to demographics, clinical features, disease activity levels, patient reported outcomes (functional ability/CHAQ score, arthritis related pain), medication use, and quality indicators. Drill down capability enables identification of patients. Results: Currently, data from 8 sites, 1161 patients, and 5334 clinical encounters are included in the population management tool (Table 1). Individual site usage of the population management tool is variable ranging from infrequent use to regular use at monthly population management meetings. The PR-COIN network is currently developing strategies to promote consistent usage of the tool at sites. Clinicians routinely using information provided through this tool report satisfaction with its functionality and ease of use; furthermore they report enhanced ability to proactively identify and address specific patient needs prior to and during clinic visits, optimizing care. Table 1. Aggregate patient data report from PR-COIN population management tool Characteristic N = 1146 a Per Wallace criteria; b PGA scale 0–10 c CHAQ = 0; d per Hellinghaus guidelines Age (years) < 2 4 (0.3%) 2–4 84 (7.6%) 5–7 148 (12.9%) 8–12 324 (28.3%) > 12 583 (50.9%) JIA subtype Oligoarticular persistent 236 (20.6%) Oligoarticular extended 132 (11.5%) Polyarticular, RF negative 396 (34.5%) Polyarticular, RF positive 99 (8.6%) Enthesitis related arthritis 63 (5.5%) Systemic 75 (6.5%) Undifferentiated 25 (2.2%) Disease status Clinically inactive disease on medicationsa 264 (35.9%) Active uveitis 71 (6.2%) Prior history of uveitis, currently inactive 100 (8.7%) Physician global assessment (PGA) = 0–3b 991 (86.4%) Optimal physical functionc 507 (57.1%) Pain score = 0 482 (42%) Other measures Compliant with uveitis screening 351 (30.6%) On biologic medication 418 (36.4%) Conclusion: The population management tool allows real-time feedback to sites regarding overall JIA population and individual patient status. Customized, “on demand” population measurement and quality improvement reports generated by the network and participating sites and can be used to identify gaps in patient care and at-risk subpopulations that may benefit from more intensive or between-visit care. Current efforts include developing a care stratification scores that can assist in identifying at risk JIA subpopulations and provision of individual patient reports that can be used to assist in pre-visit planning. Future goals include providing feedback to individual patients about their disease status compared to local and network aggregate data, and customized educational and interventional tools that can be provided to JIA patients and families. Thus, the PR-COIN JIA population management tool can be leveraged to improve JIA network and site performance and individual patient care.

Behcet’s disease is a chronic multisystemic inflammatory disorder characterized by orogenital ulcerations, uveitis, and occasional cardiac involvement. This report describes an atypical presentation of pediatric Behcet’s disease with pulmonary emboli and a cardiac mass. A 16-year-old boy with a 2-year history of oral ulcers presented with weight loss, fever, joint pain, and a large tumor adhering to the free wall of the heart’s right ventricle. Surgical biopsy demonstrated endomyocarditis with thrombus formation and led to the diagnosis. At the 2-year follow-up evaluation, intracardiac thrombus and pulmonic emboli had not recurred. Symptom control with immunosuppressive therapy was good.

Whereas the long term goal of the work described focuses on issues related to estuaries in general, specific attention in this paper focuses on one – Weeks Bay, Alabama. This estuary is one of seventeen estuarine research reserves established as “natural field laboratories” for long-term scientific and educational programs (See Figure 1). Initially, Weeks Bay will be assumed to be a well mixed estuary such that two-dimensional (depth averaged) modeling can be used. The Waterways Experiment Station Implicit Flooding Model (WIFM), developed by the U.S. Army Corps of Engineers, Vicksburg, Mississippi is used. Complete data sets at equatorial tidal conditions were chosen from the field data available. Good agreement of model results with field measured water elevations was noted. These results are typical of the kind of agreement that is expected from two-dimensional depth averaged model simulations. As anticipated, there seems to be little or no movement of salt along the western shoreline when the Bon Secour Bay salinities are low. This indicates selective flow of Fish River water down the western side of the bay with a corresponding preference for Bon Secour Bay water to flow along the eastern shore.

A new organosolv pulping method has been investigated. Delignification can be carried out by digesting the lignocellulosic material in an aqueous solution of ethylenediamine (EDA) and ethanol (EtOH) in combination with catalytic amounts of anthraquinone (AQ). This aqueous EDA-EtOH-AQ pulping is found to be highly selective in delignification and is flexible to softwoods. Bulk delignification was found to take place according to a pair of first-order mechanisms, like aqueous ethanol pulping. In the initial phase of delignification more than 50% lignin is removed, while the rest is extracted in the second slower step. The rate constants for each step are of the same order of magnitude and higher than those obtained in ethanol pulping. This indicated that overall delignification is faster when compared to aqueous ethanol pulping. The Arrhenius activation energy for the initial step was found to be 6.4 kcal/mole. The high selectivity in the detignification during the EDA-EtOH—AQ process is observed at all lev...

A two-stage acid hydrolysis process is currently used in the production of ethanol from hardwoods. In this process, dilute sulfuric acid in water at high pressure and short residence times hydrolyzes the wood and first stage substrate. The chemical action is particularly impeded in the second stage by the presence of acid condensed lignin. Presulfonation followed by delignification is proposed using a sulfur dioxide/water sulfuric acid/ethanol treatment step in place of the first stage acid hydrolysis step to alleviate this problem. Results presented include the effects caused by varying treatment time, sulfur dioxide concentration, temperature and ethanol concentration on the degree of delignification, and, on the recovery of C5 and C6 sugars in the hydrolysates. A preliminary economic feasibility analysis is made to determine the impact of improved ethanol yields and lignin by-product values in the production of ethanol from hardwoods.

Batch delignification of southern yellow pine using aqueous solutions of ethanol and 1-butanol have been studied at a temperature of 175°C. The extent of delignification, hemicellulose hydrolysis of the pulp, and monosaccharide appearance in solution are reported. From these data the relationship of bulk delignification, hemicellulose behavior and solvent selectivity can be used to better explain pulp yield from alcohol: water treatment processes

Aqueous ethylenediamine-ethanol-anthraquinone (EDA-EtOH-AQ) pulping of Southern Yellow Pine was studied for lignin removal and pulp yield. Temperature, time and ethylenediamine concentration in the solvent solution were studied and equations for lignin content and lignin-free yield were developed. Lignin content is decreased by an increase of temperature, time or EDA concentration. Lignin-free yield of pulp decreased with an increase in temperature or time, but increased with increasing EDA concentration. Overall, the solvent is selective, that is, large quantities of lignin are removed while the retention of cellulose remains high.

Nonequilibrium modeling of pyrolysis gas products flow through char layer of ablative heat shield

Charring ablator char zone nonequilibrium flow and chemical reaction kinetics as function of temperature, using thermal environment simulator

Charring ablative composites pyrolysis products composition determination, comparing chemical analysis techniques

The differential equation describing the temperature pro file in the carbon zone of a charring ablator was simulated on an IBM 7040 digital computer using MIMIC, a digital- analog simulator language. This differential equation de scribes a nonlinear, two-point boundary value problem, thus requiring an iterative procedure to converge to a solu tion. In order to handle the iterative procedure, the logical- control-variable feature of MIMIC was especially useful.

The threat of man-made and natural disturbances to the coastal environment is a continuing and perplexing problem. With the advent of rapid, numerical simulation models describing coastal water behavior, the ability to better understand these regions and to provide data to offset the adverse impacts caused by these disturbances, has greatly improved.

The objective of this study is the application of hydrodynamic and material transport mathematical models for Mobile Bay in predicting sediment transport and deposition profiles within the bay system. Of particular importance are the seasonal variations of sediment distribution which are critically influenced by current patterns within the estuary. Both point and non-point sources of sediment will be included in the analysis. Results will be presented in two ways. The first or long term variations in sediment distribution will be assessed by correlation with tidal cycle average velocities at various locations within the bay. Calculated distribution patterns will be compared with observed bathemetic data over the past century. The net effect of the construction of the Mobile ship channel on deposition patterns within the bay will also be evaluated. Secondly, short term variations in sediment transport and deposition resulting from man-made and natural disturbances will be analysed using a sediment transport model. This model will include deposition, bulk fluid transport and resuspenslon characteristics and will be capable of predicting localized, short term sediment patterns from maintenance dredging operations within the bay. Model trend results will be compared with field data collected during recent dredging activities and high altitude photographic data obtained for the bay area.